Varicocele is an abnormal enlargement of the vein that is in the scrotum draining the testicles. The testicular blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord on their way to the testis. Upward flow of blood in the veins is ensured by small one-way valves that prevent backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the veins near the testis, leading to the formation of a varicocele.
There are three types of surgery and one so called non surgical procedure. The three surgeries all involve surgical ligation, i.e. surgery to tie off the faulty veins.
1. Varicocelectomy (Conventional Open Surgery)
This is the most common procedure. In a conventional varicocelectomy the doctor makes a two or three inch incision below the groin area or in the abdomen. He goes in and ties off the offending veins. This procedure is performed on an outpatient basis (i.e. no overnight hospital stay) using general or spinal anesthesia. You may need to avoid strenuous activity for several days or even weeks after surgery. Most men are able to go back to work within three to four days.
Microsurgery (also called microsurgical ligation) is a procedure in which a smaller incision is made. The doctor only cuts the skin and fatty tissue. Because he does not cut the muscle, there is less pain and a faster recovery. The doctor identifies the varicoceles (swollen veins) through an operating microscope. Large varicoceles are cut and stapled closed. Smaller varicoceles are cut and stitched shut. The operation takes less than an hour and recovery time is short.
The microscope enables better identification of the artery that brings blood to the testicles and preservation of the lymphatics, eliminating the risk of hydrocele (accumulation of fluid around the testicles) after surgery. This procedure has a higher success rate, fewer complications, and leaves a smaller scar.
The operation takes about 45 minutes for a varicocele on one side of the scrotum, 1.5 hours if the varicocele involves both sides.
This is similar to conventional open surgery and the incision is usually made on the abdomen. High ligations (i.e. in the abdominal area rather than the groin) in open surgery require either large incisions or small incisions with significant retraction (i.e. pulling the veins out of the body), both of which can result in increased postoperative pain and infection.
There is a relatively high incidence of arterial injury while making the incision and a greater incidence of hydroceles following laparoscopy.
4. Coil Embolization, Radiologic Balloon Occlusion or Radiologic Ablation ( Non-Surgical)
This is referred to as a minor procedure or a non-surgical procedure. It is is not very commonly performed. A steel coil or silicone balloon catheter is inserted into a vein on the leg below the groin and passed under X-ray guidance to the testicular vein. Alternatively, pure alcohol is injected into the veins, causing them to become nonfunctional. After the procedure, the catheter (a small tube) is removed and no stitches are needed.
This procedure is performed on an outpatient basis and requires no incision, stitches, general anesthesia or overnight admission to the hospital. Several studies have shown that embolization is just as effective as surgery. Patients return to full activities in a day or two. Some complications of surgery, such as hydrocele (fluid around that testicle) and infection are virtually unheard of.
Minor complications such as bruising at the catheter site, nausea or backache may occur, but are uncommon. Infection, hydrocele or loss of a testicle have not been reported after coil embolization. However, there is a danger that the coil could migrate to the heart and cause death. Perhaps this is why this procedure is rarely performed. Also, it is more expensive, less effective and has a higher rate of recurrence (5-11%).
It requires a significant degree of technical expertise, and may not be doable in as many as 30% of patients. Radiation exposure during the procedure may be harmful to the testicles. The amount of radiation exposure is about equal to the amount received during a chest x-ray.